The Great Niacin Debate: AIM HIGH, HPS2 THRIVE

August 30, 2019

Hello this is Dr. Ford Brewer with
state-of-the-art heart attack stroke and cancer prevention. Why depend on a messy
and unreliable cure when you can prevent it in the first place? Today we’re going
to talk about niacin. It’s a big topic. There’s been a lot of debate about niacin over the past decade. We’ll cover a little bit of that. First of all: what
is niacin? It’s vitamin B3 (NOT D3, B3 ). You put it together with nicotinamide (which is a
related compound) and that’s the vitamin B3 (NOT D3) structure. (I finally catch & correct myself here) The vitamin d3 complex – oops –
or B3 complex. What is it for? From a historical perspective it was found to
cure and prevent pellagra. What is pellagra? Well it’s a multi-system
problem. One of the key problems that you have with pellagra is a dermatitis skin rash) – that
can become very severe. This is a picture of an individual with pellagra
dermatitis. It also causes a thing called black tongue. This which is a
picture of black tongue. As you can see this is not a subtle finding. With
black tongue – it’s obvious. It’s not something that’s easy to
miss. In fact, some of the first names for vitamin (did I say D3 again? – It’s B3 – Wow! I needed coffee, didn’t I? Worse repeated video bloopers yet!) were P P factor – pellagra
prevention factor. This was originally discovered back in the late 1800s and
confirmed in the early 1900s when a researcher withheld niacin in the diet
of dogs until they developed black tongue. Then he gave them this PP factor
nicotinamide- or niacin. I started to say nicotine.
Here’s why. I started to say that – here’s how that researcher created his
niacin. He took this molecule – if if there are biochemists out there, some of you
may recognize that as nicotine. This is the niacin. This is common to niacin
and nicotine. All he did was oxidate (oxidize?) this – and ended up with not two
oxygen molecules on a carbon there. So he took that ring off right
there. This is niacin and again he made it from nicotine. An interesting
thought about … Some of the reasons why nicotine may have such an impact that it
does … it messes so many things up. (so many reactions that niacin is involved in). Speaking of being involved in a lot of processes
niacin is involved in over 450 metabolic processes. You may recognize this is
the mitochondria. Again biochemists in the group may recognize and remember
things like the TCA cycle (Krebs cycle) – and oxidative phosphorylation.
– especially all involved NADH NADPH . The N stands for nicotine.
Nicotine is a major component in many areas of our metabolism well. So what’s
the big deal about nicotine? I mean not nicotine – What’s the big deal about
niacin? It is the only medicine – prescription or otherwise – that’s been
shown to have all of these positive effects. It’s the only thing that
improves lp(a). Niacin is (currently) the only thing that will. ( There is a lot of promise for the new anti-sense drugs). There aren’t – we have found
some other things recently (anti-sense drugs which may help) – but the only thing that raises HDL. It lowers
LDL. It lowers MPO (myeloperoxidase). Remember we talked about the Joker. It
has multiple other positive impacts in terms. Especially
the topics that we talked about – oxidation, inflammation and
cardiovascular disease and lipids. Lipids (being cholesterol and triglycerides) in
our blood our fats in our blood. So there has been a lot of debate. As I mentioned
earlier, over the past ten years about niacin it revolved around two studies:
One of them was AIM HIGH and the other one was HPS 2 Thriv. HPS2 Thrive came
out first. It was set up by Merck, I think – the maker of of the medication.
They put lapropriant with niacin. Those of us who took niacin back in
that time period – 2008/2009 – may remember they came up with
a version of niacin. It was “NO Flush”. Remember niacin causes a flush. It
causes a flush because of prostaglandins. You remember that term. If you don’t
you’ve got a couple of videos. That mention – prostaglandins the video on
aspirin (and a couple of others). Prostaglandins – you might recall – were
originally named because they were discovered from the prostate gland. At
that point they felt that that was made by the prostate gland.
Since then they found that most tissues create prostaglandins. Prostaglandins act
like like hormones but they don’t course through the entire body. They just are
very locally acting. What’s the thing about niacin and prostaglandin? Nicin
has a prostaglandin effect. That prostaglandin effect results in vaso-
dilatation. In other words the arteries – small arteries and capillaries
dilate. When they do (and that’s in the skin) . Yyou get that flushing and itching.
That’s what causes all that. They discovered a chemical called Lapropriant – which stopped it. It blocked the prostaglandin receptors that niacin was
hitting withthat flush. So you didn’t have the flush anymore. It was
very comfortable. What they found out ( getting back to
HPS 2Thrive) was the mechanism regarding why HBS 2Thrive didn’t work.
You blocked that prostaglandin (or prostate receptor). You didn’t get the
flush>but unfortunately you didn’t get the positive impact of the niacin either. So it does appear that that a lot of the positive impacts of niacin do have – do
depend on that prostaglandin impact. I give – I recommend (and I take) niacin.
What
you see today is people do have very few problems with niacin. The reason is it’s –
there are extended-release types of niacin – where you get very very little
impact. Pardon me for that spoiler. But it needed to be there. I’ll just make one
other comment. So after HPS – or a couple of other
comments about HPS2 Thrive and AIM HIGH. HPS2 Thrive saw that are
indicated that – there was NOT an improvement in cardiovascular events – in
patients taking niacin and the anti flush agent. So guess what. The
the press said, “niacin doesn’t work. Niacin has got problems.
Doctors say cholesterol drug too risky to take. ” That was in The New York Times, the Daily. The
Boston Globe said niacin causes serious side effects. Of course there are
side effects with these medications, niacin included. However – like my mom
said used to say, They threw the baby out with the bathwater. They threw out the
good with the bad.” Niacin – which does work when they threw
out the program. Now that would have been easy enough for the niacin camp to
overcome. In fact, they were working on overcoming that. Then they got hit
with AIM HIGH. AIM HIGH – the M in AIM HIGH stands for metabolic syndrome. This
was looking specifically at that huge portion of the baby boomer population
where you have what’s called the lipo dystrophy – usually from diabetes. Now let’s don’t get
confused over terms. Lipid just means fat and dystrophy means bad. Like muscular
dystrophy – a problem. The lipodystrophy of diabetes is – you have a low HDL( which
is not good) and a high triglyceride they were looking specifically at this group.
They gave them niacin I think it might have been niacin
in addition to a statin. What they expected to see was an improvement. They
did not now there was again. The press came out again saying, “Yep, that proves it!
The the niacin doesn’t work well.” Again a couple of headlines about that
debate, ” niacin doesn’t work and is harmful,” in the New England Journal that AIM HIGH folks came out and gave their information regarding it. The bottom line
was saying that “niacin didn’t work” – was ignoring tons of other studies – meta
analyses that indicates that niacin does help. That study – coronary drug project the
Oxford study several others so I’m not going to try to prove to you that niacin works. In fact I can’t. I’m not the arbiter of reality. I can just tell you
what’s been going on in terms of the debate. And I can just tell you what I’m
doing. I’m taking niacin two grams a day I occasionally will get a flush. It’s not
bad at all because I take Rugby brand extended-release. Thank you for your interest.

98 Comments

It is very hard to tolerate Niacin- the flush is hardly bearable. It causes a long lasting pruritus and I could scratch my legs all the day long.. I wait for your management suggestions to cover the problem.A lower dose would not help? I did not find an extended release version of Niacin.Must have another look.Did your Lipid-profile improve with Niacin?

Are you aware of this study wrapping up at McGill university in Canada that is specifically looking at the effects of niacin on the progression of aortic valve stenosis?

https://clinicaltrials.gov/ct2/show/NCT02109614

* * * * *

Aortic valve disease is the most common form of heart valve disease and is a major burden to society. Aortic valve disease is also expected to become more prevalent with the aging of the Canadian population. Currently, over 1 million individuals in North America have aortic stenosis, which is a narrowing of the aortic valve, and leads to symptoms of heart failure and sometimes death. Valve replacement with its potential costs and complications remains the only avenue for treatment, once symptoms develop. Despite the major importance of this disease, there are currently no medical treatments to prevent the development of aortic stenosis.The lack of preventative treatments stems in large part to a poor understanding of the causes of this disease. Using cutting-edge genetic technologies, the investigators have recently identified that individuals with a genetic predisposition to elevations in a type of cholesterol not normally screened, called lipoprotein(a), have a much higher risk of developing aortic valve disease. The investigators have also shown that lipoprotein(a) causes hardening of the valve, a very early sign of valve narrowing. The investigators plan to evaluate in a randomized controlled trial whether lowering this unusual form of cholesterol at an early stage of this disease could slow or stop the development of aortic valve narrowing The investigators are currently proposing a pilot project to evaluate the feasibility of this type of study. If successful, our proposed treatment would be notable in two ways. First, it would represent the first medical treatment to prevent valve disease, which could lead to major reductions in the societal burden of this important disease. And second, it would herald a major success for genomic medicine as it would represent one of the first treatments borne from recent genetic studies. In these ways, our proposal could significantly impact the health of many Canadians while also highlighting the innovative research performed in Canada.

Hi Dr. Brewer, I have high Lp(a) Here are my numbers:TC – 339LDL-C 250HDL-C 64Tri – 87Non-HDL-C 275Apo B – 198LDL-P 3103Small LDL-P 1384sdLDL-C 36Apo A 147HDL-P 37.6HDL2-C 22Apo B 1.35Lp(a)-P 265I do take niacin(slow release) 1000mg along with fish oil, DHEA, and other supplements. I am also following the Wheat Belly diet by Dr. Davis. The cardiologist I'm seeing prescribed 10mg EZETIMIBE & 40mg Atorvastatin. I am not taking either. I'm in my 60's and am not on any medications. I've heard too many stories about the side effects from statins. My brother was on statins and still had a heart attack even though his numbers were good. So, I don't see a reason to start on statins if it's just so the numbers look good. I have no other health problems except for the high cholesterol. I'm off all grains and sugars since January. I'm having the calcium test done and nuclear stress test to see if I have any plaque buildup and how much. Question for you, should I increase the niacin since I have no flushing effects? I've read where L-carnitine also helps to lower Lp(a), what are your thoughts?

WE ARE IN SÃO PAULO. MY BROTHER WLADIMIR IS SCHISOPHRENIC. IT IS 1 MONTH HE STARTS TO TAKE NIACIN 500. HIS VOICE IS EXCELENT. HE STOP PED TO TELL WRONG THINGS. HE IS NO STORBORNED. HE IS BETTER SOCIALLY.HE IS 43 YEARS HE GOT SICK WHEN HE WAS 16.HE IS EXCELENT MUSICIAN.

The way to cope with the flush is to start with very small doses, e.g. 25 mg, and slowly, very slowly, build up. I regularly take the 3g or so per day, suggested by Dr Abram Hoffer, and provided I keep it up every day, barely notice a flush. It only comes back if I leave off niacin for days at a time. I use pure nicotinic acid powder, either mixed weith water and drunk through a straw (it doesn't taste particularly good), or ideally put into gelatin capsules. I usually mix it with vitamin C powder to make this process easier, as the niacin powder is very fine. In any case, Hoffer recommended taking vitamin C with it.

Like some others, I don't mind the flush when it occurs; in fact I quite like it. The thing is to be prepared for it, and expect it. I can imagine it would be alarming if you had no idea what was going on.

Great video, but it might have been nice to acknowledge Dr Abram Hoffer's part in the history of niacin therapy. See his book: "Niacin: The Real Story".

For some reason, I thought Niacin and Niacinamide were the same thing. Apparently, Nicinamide is supposed to be the flush-free stuff, which seems to be effective on mental impairments, but not on heart disease. I used to look forward to the Niacin flush, but now they say, after a couple of weeks, you don't get it anymore, so it's only a temporary effect. For now, I take only 500 mg daily (morning/evening), but I might consider upping that. Now, should I still be taking that with Lisinopril? Who knows.

The next big question is whether Niacin alters our cellular levels of nicotinamide riboside (NR), or am I thinking of Nicotinamide Adenine Dinucleotide (NAD+), which is reduced in our cells as we age, but which is one of the Sirtuins, which act as "gene snippers" that turn off the genes that make us age (if my old memory serves – I may have to go back and review those papers). Apparently, a lot of our "Nico_" enzymes are derived from Niacin, so perhaps it helps, and might be a less expensive alternative to NAD+ supplements (which you can now buy, but are very expensive).

Dear Mr. Brewer. Is there any way to make that flush appear every time? PGD2 seems to play a role in male pattern baldness, I came here from a video that did explain the niacin flush leading to PGD2(https://www.youtube.com/watch?v=ai-F62w-XYI&feature=youtu.be). Then reading more about it, I figured out that the body eventually going get used to it. Is there a way to make sure to flush every time? Like a certain number in grams or maybe pausing it one day/week etc? I would be happy to get an answer!

I appreciate your help so much. Looking for some Niacin but the ingredient list never mentions Nicatonic Acid. I only found one and it said "as nicatonic acid" not sure if thats a sly play on words or legit. Are you able to give any suggestion s on the best quality to purchase?

The flush I can handle; its the 2 day headache that Niacin causes me. Used to take Niacin for years…then I stopped for a few yrs. When I started back up, 2day headaches are the norm. Why? I only use straight Niacin, not slo niacin.

Hi Dr. Brewer! Thank you for your help in clarifying the debate. Your opinion seems to be that high dose niacin is safe for lowering LDL-C if there are no serious side effects, but is it safe for long term use? Thank you for the opportunity to ask this question.

Yes, I agree that the 0.1% variance in hba1c is not significant. You convinced me a while back that niacin is more beneficial than not. I have been working with a naturopathic doctor who had introduced me to niacin in the first place. I had just wanted you to reassure me of its safety. The frustrating thing is that being on a ketogenic diet and 16/8 intermittent fasting for 12 months only lowered my hba1c from 6.3 to 5.9. Then taking niacin bumped it back up to 6. So annoying! I am so convinced it's the Amilioride HCL/HCT 5/50 that is keeping it high despite my efforts. Will try to get the nephrologist to lower the dose. Thank you Dr. Brewer and Mr. Lorscheider for your help.

I am a 50 year old female. Had my Calcium score done 2 weeks ago where the results says my score is 93 and at 100% percentile. I have been taking Vit D3 and K2 for more than a year now. I do Zumba for 4 years and yoga for six months maybe 3-5 times a week. I eat mostly veggies, sardines, salmon, nuts, very little carbs, some meat 2 to 3 times a week. I sleep between 6 to 8 hours everyday. My labs from 12/18 are as follows: total chol=319, HDL=113, LDL=185, trig=92, A1c=5.1, glucose=81, HS CRP=1.3, Vit. D, 25-OH=54, homocysteine= 7.9, TSH=1.82. Had some fatigue symptoms a month after, did labs again 1/2018, results of TSH=3.9 up from 1.82, free T3=2.3, free T4=1.2. I started taking Iodine, selenium, thiamine, B12, Vit C, Magnesium for a month now. Any advice pls where to go from here. Should I take Niacin, statin, aspirin? Have not seen any cardiologist bec. I know they will prescribe statin and aspirin. I am 5'3", 121 lbs, waistline=26. Grandfather died at 39 from heart attack, mom does not have CVD. Dad died from a fall at 84. I don't take any Rx meds. B/P been 100s/60s both arms. PLS ADVICE.

I take just before bed one regular flush Niacin 500mg and if flushes , is when I sleep, no problem. I also take twice a day 500mg each of Niacinamide which is different and also a multitude of other antioxidants. At 72 my BP is normal and so far most everything is under control..and working to change the ED condition..perhaps this subject is very important to most men to address at some point Doc..Please move your microphone up closer for better sound clarity and volume. Thanks !

I buy the Rugby nicotinic acid Niacin proper. I note that the 'slow release' version may be more harmful to the liver. I also have the other B3 version nicotinamide… and noted that apparently…" Nicotinic acid is a B vitamin that is available without a prescription as a vitamin supplement (niacin). The nicotinic acid form of niacin lowers cholesterol, but other forms of niacin do not. These other forms that do not lower cholesterol include nicotinamide and inositol nicotinate (also called no-flush niacin)." WebMD

niacin i tried various doses but it gave me a fast hard heart beat.I would wake up at night heart pounding and that worried me.The mood effects were excellent but i had to stop due to heart.I am trying niacinamide to see if same side effects.

Here Dr Andrew Saul states that niacinamide doesn't have the same cholesterol effects as Niacin proper (nicotinic acid) and inositol hexanicotinate https://youtu.be/mFN0cv5cpZQ?t=568(Andrew W. Saul is Editor-in-Chief of the Orthomolecular Medicine News Service and is on the editorial board of the Journal of Orthomolecular Medicine. He has published some 200 peer-reviewed articles, and has written or coauthored twelve books.)

I need some clarification. You state taking 2 grams (2000 mg) yet I was told Men: should be 16 to 25 milligrams daily. Please explain how my body can handle the extremely higher amount 2 grams (2000 mg) you suggest. I need the benefits you are describing. Someone else suggested I use Trimethylglycine (TMG) powder for better control over the higher dose. I was told to match my Niacin dose to a corresponding dose of trimethylglycine (TMG). Dr. Brewer will this help?

I am so confused. 60 year old female recently diagnosed calcium score and very high LPa apparently heterozygous with high level of food sensitivities…whatever that means. I would like to lower LPa with B3 but instead put on Crestor which apparently raises it and Zetia which I think has something to do with the food sensitivities. Providers always too busy to explain anything. One doc says B3 and another warns of stroke association.

I am 53 year old and 65 kg and 164 cm height. I took 1.5g of Niacin for about 2 months to reduce cholesterol. Positive effect was my blood pressure went down from 140/90 level to 110/70. I have not check my cholesterol level yet. Negative effects were nausea, vomiting and cannot take meaty food. I totally stopped Niacin for two days and these symptoms disappeared, but my blood pressure went up again. I am taking 500mg a day now for a week without much of side effects. I am worried with liver damage from niacin. I am wondering if any reported severe liver damage from Niacin. Thanks.

I have low HDL and high Triglycerides. After reading a book by Abram Hoffer about niacin I started taking 1000 mg. niacin at lunch every day. I also started taking 500 mg. niacinamide at breakfast and dinner (total of 1000 mg.) because of, according to the author, benefits for arthritis sufferers. This is a total of 2000 mg./day. After about 3 months I got a Cardio I.Q. test. Nothing but very small changes. I wonder if the niacinamide is blocking the benefits of the niacin. Any thoughts?

Wondering what dosage of niacin would be effective? Would 500mg immediate release morning and night be enough to have an effect, knowing that presciption niacin is often in the 3-6 g daily range? I already take lipitor and I read somewhere that niacin and artovastatin work well together, somewhere else there was some doubt. Have you seen this also? I see you take extended release – i have been reading that extended release isn't recommended because the liver needs a break from niacin

The flush seems to be important. Plus there seems to be hepatoxicity with the extended release version. I'm using to treat my alcoholism and helps reduce the anxiety. I can feel it coming on and always induces a great calm that can last for a couple of days. I'd probably experience even greeter improvement if I was to give up smoking cannabis, though I started to help me deal with the dreadful summer heat.

I take a No-flush Niacin supplement daily ( from Swanson's ), that hasn't seemed to work. Niacin Flush-Free from inositol hexaniacinate , 500 mg., also contains Inositol from inositol hexaniacinate, 140 mg.. I take only one before bed. I'm not on a Statin, too many side effects. Should I try a regular Niacin? Rugby brand, 2 grams, as you do? When do you take yours? Before bedtime or morning? I was on the prescription brand, years ago but the flush was too much for me to take and I was also going through menopause and was experiencing a flush because of this as well. I'm 65 yr's young and have had familiar hyperlipidemia all my life. Low H.D.L. and high triglycerides. Your input would be greatly appreciated. Thank you.

Question can Niacin Make all yours joints,wrists,ankles etc hurt terribally,i started niacin on my own less than 2 months ago, was taken off lipitor,because after taking it for over 10 yrs it gave me Myositis of the legs?

Doc, theres no debate. Theres only taking 3 grams, or taking less. Abram Hoffer cured not only schizophrenics, but also lung cancer at that dosage. Failure to replicate similar results stems from studies deliberately set up to fail.

I forgot to slowly build up to a niacin dosage I could handle and last night I took a 2000mg capsule. I got so hot that I actually passed out and woke up on the floor. (with a black eye!) I gasped when you said you took 2g a day! I think I may need to find this "extended release" niacin. I really don't want to go through that again.

I’ve been taking 500 mg of extended release niacin daily along with Matt Foreman daily or twice daily I’ve had significant health improvements but I’m thinking about switching to niacinamide because I read that extended release niacin is very toxic to your liver you sound very knowledgeable if you could give me advice on which one would be better thank you.

Hi Dr. Brewer, I love Niacin and take high dosages ( approx. 3000 mg/day) but a read a comment that "it also inhibits lipolysis from adipose…. meaning you can’t break down fat into FFA." Are you aware of any truth to that statement? Thanks.

I appreciate your honesty in saying you can't promise taking niacin helps the end point. I took a big interest in heart disease a long time ago. Studied it hard for 12 years. After the recent string of failures of drugs that did all the right things, but failed to improve outcomes in heart attacks and strokes, I came to the conclusion we were treating a lab report, and not the disease. Thank you for posting these videos.

I just started taking “no flush niacin” (inositol hexanicotinate) to help raise my HDL and lower my triglycerides, in addition to 2500 mg of omega-3 fish oil. Do you know if the “no flush niacin” works as effectively as straight niacin? (It is essentially a niacin ester that hydrolysis slowly to liberate free niacin.) Thank you for the very informative video!

Who cares about the flushing? If it raises HDL and lowers blood pressure…I restarted taking Niacin after I dismissed it as I read that it might be "harmful to the liver". Such conflicting information I'm sure is all road-blocked by Big Pharm, which in case you haven't seen, is getting worse with blocking Google searches on good, functional medical advice.

You're THE BEST Dr. Brewer! Thank you for ALL you do for All of US! I post you on Facebook and my 5k viewers regularly! Geez, I wish you were local in Los Angeles so I could have a visit with you!Ever do events here?? Best to you! ; o ) Hugo Rojas

Dr. Brewer, India is so horribly gripped by Big Pharma culture that Niacin (Nicotinic Acid) is not manufactured by any a single pharmaceutical company and those which did have all stopped it's production altogether in favour of fibrates and statins. Niacin is not available anywhere in India execpt for muscle industry for flush which is 35 times more expensive than the therapeutic ones sold 3 years back.